What if there was a health insurance program that covered every single thing your child’s doctor prescribed for him or her? Every therapy, every medication, and every supply? If you have a child under age 21 enrolled in Medicaid, this program actually exists, though states don’t always follow its rules. It is called EPSDT, which stands for Early and Periodic Screening, Diagnostic and Treatment program.¹
In 1964, an influential report entitled One Third of a Nation determined that one out of three military draftees had some sort of disability or medical condition. Most importantly, this report demonstrated that most of these disabilities could have been eliminated through proper medical care and rehabilitation, had they been diagnosed and treated during childhood. The problem was particularly severe in children who grew up in poverty.
To respond to this problem, and to ensure a healthy and capable military force, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit was added to Medicaid in 1967. It included more comprehensive benefits for children to screen them for disabilities and medical conditions, and to treat any identified problems.
EPSDT was strengthened further through the Omnibus Budget Reconciliation Act of 1989, which made it mandatory for all states to cover all mandatory and optional benefits for children under age 21 enrolled in financially-based Medicaid programs.
EPSDT requires states to cover all Medicaid services listed in federal Medicaid code, specifically 42 USC §1396d. These include the following:
- Inpatient hospital services
- Outpatient hospital services
- Home health services
- Physician services
- Rural health clinic services
- Federally qualified health center services
- Laboratory and X-ray services
- Family planning services
- Certified Pediatric and Family Nurse Practitioner services
- Transportation to medical care
- Prescription Drugs
- Clinic services
- Physical therapy
- Occupational therapy
- Speech, hearing and language disorder services
- Respiratory care services
- Other diagnostic, screening, preventive and rehabilitative services
- Podiatry services
- Optometry services
- Dental Services
- Eyeglasses and Vision care
- Chiropractic services
- Other practitioner services
- Private duty nursing services
- Personal Care
- Case management
- Services in an intermediate care facility
- Inpatient psychiatric services for individuals under age 21
EPSDT in Action
EPSDT starts with Early and Periodic Screening. This means that children are entitled to periodic visits with their physician from birth, and should be screened as early as possible for any medical or developmental problems. During these screenings, a physician may make a diagnosis of a problem. The physician is then required to determine a treatment plan to “ameliorate” the diagnosis.
Screening -> Diagnosis -> Treatment
This treatment plan can include any of the covered benefit services listed above, as well as any other accepted medical care is prescribed by the physician. The code states that Medicaid MUST cover, “Such other necessary health care, diagnostic services, treatment, and other measures…to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” Treatment also includes any medically necessary care to prevent worsening of a medical condition. For example, a child with a tracheostomy might receive a treatment plan consisting of private duty nursing care in order to prevent worsening respiratory symptoms. Similarly, an incontinent youth can be “treated” with diapers. A child with asthma may be treated with medication, while a child with autism may be treated with intensive in-home therapy.
State plans often include limits on types of treatments, amounts of treatments, or types of medications. Under EPSDT, if the child’s physician deems a treatment is necessary, the state MUST cover it as long as it is medically necessary, even if it is not part of the regular state plan. For example, if a child needs 200 catheters a month and the state plan only covers 30, the state must pay for 200 catheters a month under EPSDT if the physician explains why it is medically necessary. EPSDT can be used to obtain more frequent therapies, medications not on the approved list, greater quantities or different brands of supplies, more private duty nursing care hours, and similar needs.
Of course states can—and do—attempt to deny services by arguing that they are not medically necessary. Unfortunately, in this situation, you must appeal their decision. Often, if your doctor simply writes a letter of medical necessity explicitly stating that the service/item is a treatment for a diagnosed condition under EPSDT, the state will be likely to approve the service or item.
EPSDT differs from traditional medical care in one other important way. States are required to not only provide EPSDT services, but to arrange for them and ensure they actually happen. As the code says, states are responsible for, “arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services.” (42 USC §1396a(a)(43)(C)) The burden is on the state to make sure your child is receiving the care he or she requires.
There are two groups of children who are always eligible for EPSDT benefits. These include children ages 0-21 who qualify financially and are enrolled in Medicaid in their states, and all children ages 0-21 in federal Medicaid waivers.
If your child participates in Medicaid but not in a Medicaid waiver, it can sometimes be difficult to determine if he/she is financially eligible for Medicaid and therefore entitled to EPSDT benefits. While states are required to offer Medicaid to children under a certain financial threshold, most states offer Medicaid to children of slightly higher incomes. States can do this in several ways, such as by expanding Medicaid to higher income children, or by developing a separate state-based Children’s Health Insurance Program (CHIP). Children who live in states that just expand Medicaid are entitled to EPSDT benefits, but states are not required to provide EPSDT benefits to children in stand-alone CHIP programs. In addition, some states have state-based medically needy or other state-run programs that may or may not provide EPSDT benefits, depending on the state’s rules.
In general, children who come from families that earn less than 138% of the federal poverty line (about $32,913 for a family of four in most states in 2014) always qualify for EPSDT. This amount, however, is higher in most states, with states like Maryland offering Medicaid expansions up to 322% of the federal poverty line, or $76,797 for a family of four in 2014. You can use this chart to see if you qualify. Find your state and you child’s age in the first three Medicaid columns, and it will tell you what percent of the federal poverty level you can earn in your state and still definitively qualify for Medicaid and EPSDT.
Another somewhat simple and usually correct method of determining if you receive Medicaid through financial eligibility is to see whether you pay premiums, copays, coinsurance or other fees. If you do not pay any of these fees, your child is most likely financially eligible for Medicaid.
If your state runs a separate CHIP program (as listed in the right-most column in the chart), your child may or may not be eligible for EPSDT benefits. Some states extend EPSDT to all children in Medicaid, whether they are in CHIP or financially-based Medicaid. Others do not. You will need to research your own state to determine if it extends EPSDT to all children in CHIP.
Children in 1915(c) Home and Community Based Services Medicaid Waivers, as well as Katie Beckett or TEFRA Medicaid Waivers, are always entitled to EPSDT benefits.
If your state operates a state-based health plan or a demonstration Medicaid program (called an 1115 Waiver), your child may not be entitled to EPSDT benefits. As of late, the federal government has refused to limit EPSDT in demonstration Medicaid programs, but some earlier programs, such as the Oregon State Health Plan, were permitted to waive EPSDT benefits.
Use Your EPSDT Benefits
EPSDT is there to meet ALL the needs of your child. If your child is eligible, ensure you make full use of these benefits to get what your child needs. It is important to note that states routinely try to side-step EPSDT or restrict services as not medically necessary. Under EPSDT, limits and restrictions are not allowed, and states must cover all services that fall into the above listed benefit categories. At times, you may need to appeal to ensure your child’s needs are met. In some cases, parents have even had to file lawsuits. But in most cases, a simple mention of EPSDT in a letter of medical necessity will grant your child the services he or she needs.
Sample EPSDT Letter
Each letter should contain the following elements:
- Make sure the relevant diagnosis is listed
- Use of the term “ameliorate” is recommended because it is the term used in the law
- Say how the condition will worsen without the prescribed treatment
- Specify what you need and how much
- Mention that it is a covered service under EPSDT
My patient, Child XYZ, has multiple diagnoses, including Down syndrome, a congenital heart defect that has been repaired, a feeding disorder requiring a gastrostomy tube, and incontinence of bowel and bladder. His diagnosis of bowel and bladder incontinence can only be ameliorated by the provision of youth sized incontinence products. Without these products, he will be at risk for skin breakdown and irritation. Please provide 200 diapers per month. Under EPSDT, incontinence supplies are a form of medical equipment that must be covered.